Supreme Court Ruling Sets Stage for Full Rollout of Health-Care Reform Law

FRIDAY June 29, 2012 -- The U.S. Supreme Court's long-awaited ruling Thursday upholding the constitutionality of the Affordable Care Act means that changes to the American health care system will roll out largely as planned when the bill was signed into law two years ago, experts say.

"The opinion cleared the way for implementation to proceed," said Karen Pollitz, senior fellow with the Kaiser Family Foundation in Washington, D.C.

Perhaps the biggest impact of the law will be the decrease in the number of people who are uninsured or underinsured. The U.S. Congressional Budget Office estimates that the rolls of the uninsured will go down by 30 million to 33 million people by 2016, leaving 26 million or 27 million people uninsured, a 50 percent reduction.

The increase in the number of people covered by health insurance comes via several different provisions of the Affordable Care Act. The most contested and controversial of those provisions is the so-called individual mandate, which requires all adults to obtain health insurance or face a penalty.

Surprising some legal scholars, the Supreme Court upheld this part of the law, as a tax, and it will now go into effect in 2014.

That means the earliest the U.S. Internal Revenue Service could levy fines would be in 2015, said Linda Fentiman, James D. Hopkins Professor at Pace University Law School in White Plains, N.Y.

But in truth, 90 percent or more of Americans won't ever feel the pinch of the penalty either because they're already covered or they're exempt, Pollitz said.

The Supreme Court decision also means that other provisions in the law -- the most significant legislative achievement of President Barack Obama's administration -- will be allowed to remain in place.

For instance, young adults can still be covered under their parents' insurance plans.

"[This allows] the 2.5 million young adults up to the age of 26 who gained coverage under the law to stay on their parents' health insurance policies," Dr. Jeremy Lazarus, president of the American Medical Association, said in a statement.

Many other Americans will be able to get health coverage through subsidized health insurance exchanges. And insurance companies can no longer exclude people from plans because of preexisting conditions.

This provision is already in place for children and will be applicable to adults starting in 2014, said Dr. Michelle Huckaby Lewis, a research scholar with Johns Hopkins Berman Institute of Bioethics in Baltimore.

The law will also preserve discounts that Medicare recipients (generally people over the age of 65) receive on prescription drugs, Joe Baker, president of the Medicare Rights Center, said in a statement.

And, in general, the expanded health coverage will boost preventive services such as mammograms and colonoscopies.

Insurance companies will now be required to provide "first dollar" coverage for preventive and screening services, explained Dr. Glen Stream, president of the American Academy of Family Physicians. Stream said he has seen many patients decline a mammogram or a colonoscopy because the co-pay or deductible was simply too expensive.

"It was not at all uncommon to decline important wellness and preventive screening because they couldn't afford the co-pay or the deductible," Stream said. "Now, the whole cost of a mammogram is covered because it fits into this category of preventive screening services."

The only part of the Affordable Care Act that the Supreme Court took issue with was penalizing states that didn't expand their Medicaid programs.

"The court said the federal government does not have the power to penalize states who decline to expand their Medicaid programs," said Devon Herrick, a health economist and senior fellow with the National Center for Policy Analysis in Dallas.

It's unclear whether states will decide to pursue Medicaid expansion or not, but this part of the ruling could affect the poor.

Lewis explained that prior to the Supreme Court's decision, "the Affordable Care Act would have required that states expand Medicaid programs by 2014 to cover all individuals under the age of 65 with incomes below 133 percent of the federal poverty level."

The federal government would pay 100 percent of the cost of expanded coverage through 2016, with the states assuming a small portion after that.

"This expansion of Medicaid would have done a great deal to eliminate much of the state-by-state variation we currently see in [the coverage of the] poor, but after [Thursday's] ruling, states may decline to participate in Medicaid expansion," Lewis said. "This would no longer eliminate disparities in coverage in the very poor from state-to-state."

On the other hand, Herrick noted, because Medicaid reimbursement rates run an average of only 59 percent of what private insurers pay, doctors may opt out of covering these people.

"If we have 16 or 17 million more people on Medicaid and doctors are saying they don't want to take Medicaid enrollees, that's not good," Herrick said. "We're afraid that could drive up emergency room visits."

And requirements that employers with 50 or more employees provide health benefits may mean a squashing of cash raises, he added.

Regardless of the perceived pluses and minuses, the Supreme Court's ruling does mean that many people are letting out a long sigh of relief.

"At least now we have some certainty about how we're going forward," said Stream. "We can work to implement those components of health care reform that are already underway that we think are in the best interest of patients... Even the strongest advocates wouldn't claim it to be perfect."

Thomas Oliver, a professor of population health sciences at the University of Wisconsin School of Medicine and Public Health, added: "This gives us the chance to fight our way to the finish line, but it's still a tough several miles ahead. What we have now is a stronger set of resources, and a set of guidelines and rules so that individuals and companies and health care organizations and insurance companies are not out there on their own."

But a fight to the finish line may be inevitable. Republicans and likely GOP presidential nominee Mitt Romney have vowed to repeal the controversial law -- when, and if, they get the necessary votes.

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